198603162-10-24-2023-28-AS-RORN-D3RUHZ-20240327153645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:11:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Valeria Maldonado

COMPLAINT CONTROL NUMBER: 28-AS-20220318093921

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS:	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Itzayana Barba- Adminstrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made a subsequent, unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Administrator, Itzayana Barba, and explained the purpose of the visit.

On 03/21/22, LPA Angelica Rea made an initial visit and conducted a health and safety check. The following was reviewed: tour of the facility, including food supply, resident rooms, bathrooms, and common areas. LPA Rea requested copies of staff and resident roster along with other pertinent documents from resident #1's file. It was determined that further investigation was required.

During today's visit, LPA Maldonado obtained a copy of the resident/staff roster, and conducted interviews with Staff# 1-5 (S1-S5) and Residents# 2-5 (R2-R5). LPA was unable to interview Resident#1 (R1) due to resident no longer residing at the facility.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220318093921

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
	VISIT DATE: 10/24/2023

NARRATIVE

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The investigation consisted of the following:
Regarding allegation: Resident sustained a fracture while in care.
It is alleged that R1 fell at the facility, which resulted in a fractured shoulder. Per incident report obtained, dated: 03/03/22, it is noted that facility reported to the licensing agency about R1 falling off R1's wheelchair on their left side, while being escorted to the dining room by staff and was attempting to reach to grab an object, while passing by. It was indicated that R1 was assisted up, observed for injury, and first aid was rendered. R1's family and hospice agency was notified. Per x-ray records obtained, it was noted that a mobile x-ray was completed by R1's hospice agency on 03/09/22, indicating that R1 had a "left humeral surgical neck fracture and AC separation". There is no indication on the report that the fracture was sustained due to a fall the resident had. Per interviews conducted with S1, S1 witnessed this fall and immediately notified R1's family, physician, and hospice care. S1 stated that R1 was assessed for injuries and did not have any. S1 also stated that R1 did not exhibit symptoms or express to be in pain at that time. S1 stated that R1 expressed pain a few days after, during a nurse visit from Hospice, and the hospice agency requested a mobile x-ray to be completed at the facility at that time. The x-ray showed a fracture, but it was not confirmed if it was due to the fall. Per S2, S2 recalls R1 getting diagnosed with a hairline fracture, however denies it occurring at the facility. S2 believes it was deemed to be an old fracture, but R1's family insisted it was new. (3) of (5) staff interviewed denied the allegation. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was wheelchair bound and had a speech impairment due to diagnosis of hemiplegia and hemiparesis. There was also no indication that R1 had a history of falls. R1 required two-person assist for transferring, but was able to propel self on their wheelchair. (4) of (4) residents interviewed could not corroborate the allegation.

Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

During the visit, no deficiencies were observed or cited.

An exit interview was conducted with Cluster Nurse, Kim Mims and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

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